CNA Webinar Series: Progress in Practice A better understanding of menopause to help you intervene with best nursing practices Gemma Aucoin-Gallant Author, Professor of Nursing (retired) Dr. Réjean Savoie Oncologist-Gynecologist Dr. Georges-L.-Dumont University Hospital Centre September 15, 2015 © Canadian Nurses Association, 2015 Josette Roussel, RN, MSc., M.Ed. Senior Nurse Advisor Canadian Nurses Association Gemma Aucoin-Gallant, Retired Nurse, MScN, PhD Dr. Réjean Savoie, F.R.C.S.C. Author, Professor of Nursing (retired), Oncologist-Gynocologist Université de Moncton and Adjunct Professor in Medicine, Université de Sherbrooke Sylvie’s story is based on the book: Published in French only Sylvie’s story Sylvie is 53 years old. She has been living with Eric for 24 years and is satisfied with her relationship with him. She has not had her period for 12 consecutive months. She has hot flashes and trouble sleeping. She has vaginal dryness that occasionally causes pain during penetration. Sylvie and her sister, Natalie, take part in an information session provided by Lisa, a community health nurse. The first question they asked the nurse Based on the results of her medical checkup, Natalie is in good general health. Yet, she experiences hot flashes, feels irritable on occasion and has not had her period for two months. Natalie asks if she is menopausal. What does Lisa reply? A. Yes, you are menopausal since you have hot flashes and are occasionally irritable. B. No, since you have not stopped menstrual periods for 12 consecutive months. C. It is preferable to consult your doctor for a hormone level test to determine if you are menopausal. D. None of the above. The nurse’s response The correct answer is B. Lisa explains to Natalie that she is going through perimenopause and not menopause. Perimenopause generally starts with a change in the menstrual cycle. During perimenopause, women may experience symptoms such as hot flashes, mood swings, sleep disturbances and irregular periods (alternating short and long cycles). This is a transition period that precedes menopause. It lasts, on average, five years. Menopause corresponds to the cessation of a woman’s period for 12 consecutive months. Natalie has only missed two periods. Once menopause has occurred, it persists for the rest of a woman’s life. Perimenopause Lisa takes part in a conference on menopause provided by health professionals. Lisa knows that the following may occur during perimenopause: A. Hyperestrogenism B. Hypoestrogenism C. Very irregular ovulation D. All of the above Perimenopause The correct answer is D. During perimenopause, the ovaries are demonstrating signs of weakness as they age. They produce estrogen in an erratic manner. The absence of corpus luteum results in a decrease in progesterone. The first hormone deficiency appears to be progesterone. During perimenopause, ovulation is less frequent. Hyperestrogenism occurs as a result of luteal insufficiency (progesterone FSH estrogen). Hyperestrogenism results in heavier menstrual periods and shorter cycles. The ovarian follicle resists FSH, resulting in hypoestrogenism. Hypoestrogenism may cause hot flashes and amenorrhea. Perimenopause is associated with hormonal instability. The second question they asked the nurse Natalie and Sylvie wonder if women are more inclined to experience depression during menopause. What does Lisa reply? A. The risk of depression increases during perimenopause due to hormonal instability. B. The risk of depression increases in menopause because hormone production has stopped. C. The risk of depression is the same for women during perimenopause and menopause. D. None of the above. The nurse’s response The correct answer is A. Lisa says the risk of depression is higher during perimenopause for women who experience mood swings, hot flashes and insomnia. Perimenopause is associated with an increased risk of both first and recurrent episodes of depression. Hormonal variations can also affect the brain’s neurotransmitters, including the production of serotonin, dopamine and GABA (gamma- aminobutyric acid). Several researchers have stated that the risk of depression decreases 15% every year after the onset of menopause. The symptoms • Most women (80%) experience hot flashes. • More than half of women (60%) experience a weight gain between 3 and 5 kilograms. This same percentage of women experience sleep disturbances. • Half of women experience vaginal dryness. • Women aged 60 and older experience more urogenital problems (vaginal dryness, incontinence) than vasomotor problems (hot flashes). Hot flashes The nurse teaches Sylvie ways to relieve hot flashes. For example: • Wear loose-fitting, light clothing made of natural fabrics and dress in layers. • Gradually take natural phytoestrogens in the forms of soya and ground flaxseed. • Reduce your stress and try to avoid situations that are upsetting. • Avoid things that trigger hot flashes: alcohol, spicy foods, caffeine. • Stop smoking. Vaginal dryness The nurse explains how to deal with vaginal dryness. For example: • Informing her spouse about her concerns and regaining sexual desire. • Placing importance on snuggling and making foreplay last. • Having sexual relations on a regular basis (twice a week or more). • Using water-based moisturizers and lubricants. • Avoiding things that trigger vaginal dryness: perfumed products, antihistamines. The third question they asked the nurse Sylvie is experiencing menopausal symptoms that she considers mild. She has no contraindication with respect to hormone therapy. She asks Lisa about the best option to alleviate her symptoms. What does Lisa reply? A. To use hormone therapy. B. To use personalized bio-identical hormones. C. To take charge of her health by modifying her lifestyle and avoiding things that trigger symptoms. D. None of the above. The nurse’s response The correct answer is C. Lisa based her answer to Sylvie’s questions on the guidelines provided by the Society of Obstetricians and Gynaecologists of Canada (SOGC). • Women must adopt a healthy lifestyle and avoid things that trigger symptoms before opting for hormone therapy. • Hormone therapy is a treatment to alleviate moderate to severe symptoms if women do not present contraindications. • Bio-identical hormones are not approved yet by Health Canada. Hormone therapy • For menopausal women who still have their uterus, hormone therapy involves a combination of estrogens and progesterones. • For those who have had a hysterectomy, an estrogen preparation, with no progesterone, is indicated. • Women must receive the lowest effective dosage for the shortest period of time (less than 5 years) and have a rigorous health assessment every year. • Hormone therapy (HT) may increase the risk of breast cancer slightly for women who take HT for more than 5 years. Hormone therapy: the decision-making process The nurse can use the personal decision-making guide prepared by O’Connor et al. (2011) to help women make decisions concerning their health. Here are the steps: • Specify the objective of the decision: what, why and when. • Identify her decision-making role: on her own; with someone else’s help; or giving full responsibility to another individual. • Determine her needs: her level of knowledge of the benefits and risks of treatment, the support she receives from friends and family, and her level of self-confidence. • Respond to all her needs to help her make a decision. Other questions they asked the nurse Sylvie asks Lisa three more questions and states her opinion with respect to physical activity: 1. Does heredity play an important role in skin aging? 2. What should she eat in terms of protein, lipids and carbohydrates? 3. What can she do to sleep better? Sylvie tells Lisa that she does not think physical activity is important. What advice does Lisa give? Taking better care of her skin • Lisa tells Sylvie that genetics plays a minimal role (10%) in premature aging of the skin. • She says that exposure to the sun plays a major role in premature aging of the skin. • She explains that UVA rays are responsible for wrinkles; tanning and UVB rays cause sunburns. • She says Sylvie should put on sunscreen (with an SPF rating of at least 30) a half hour before going outside. She also tells her to avoid tanning lamps. • She says that tobacco use also ages the skin. Eating well The nurse also talks about why it’s important to eat proteins, lipids and carbohydrates. She focuses on the following: • Obtaining 50% of her protein intake from animal sources and the other 50% from vegetables, taking her weight into consideration (0.8 grams of protein per kilogram). • Limiting saturated fats, eliminating trans fat, choosing monounsaturated and polyunsaturated fats, limiting added fat and removing visible fat. • Limiting refined sugars to 6 teaspoons per day and salt to 1,500 mg per day. • Taking vitamin D supplements every day. Sleeping well To help Sylvie sleep better, Lisa suggests: • Following good sleep rules: expending enough energy during the day, ensuring proper exposure to natural light and dark, airing out the room before going to bed, sleeping on a good mattress. • Reinforcing the link between sleep and bed: establishing a regular sleep schedule and ritual, remaining in bed the time required to sleep. • Using cognitive behaviour therapy: this therapy serves to eliminate negative nighttime thoughts and to focus on the positive. Managing stress better To sleep well, you must manage your stress effectively. Here are some acknowledged strategies: • Reduce drama in your life. • Accept imperfection. • Take a step back. • Set limits. • Manage day-to-day problems effectively. • Use relaxation strategies. Physical activity during menopause Sylvie tells Lisa that she does not see the importance of physical activity. What advice does Lisa give? Lisa uses the “transtheoretical model” to give Sylvie advice. She determines that Sylvie is at the “precontemplation stage”. Here is the advice given by Lisa: • She informs Sylvie about the health benefits of physical activity. • She suggests finding a fitness partner. • She invites her to read about physical activity and prepare a list of the advantages of taking part in it on a regular basis.